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Archived: Dimak Healthcare

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Inspection report

Date of Inspection: 5, 18 October 2011
Date of Publication: 15 December 2011
Inspection Report published 15 December 2011 PDF

People should be given the medicines they need when they need them, and in a safe way (outcome 9)

Enforcement action taken

We checked that people who use this service

  • Will have their medicines at the times they need them, and in a safe way.
  • Wherever possible will have information about the medicine being prescribed made available to them or others acting on their behalf.

How this check was done

Our judgement

People using the service are at risk because of unsafe medicines management.

User experience

People who required help to take their medicines told us that staff were helpful and efficient and that they had experienced no problems with receiving medicines correctly.

Other evidence

Following our last inspection we had concerns about the way people were supported to take their medicines and the poor standard of medicine records.

During this inspection we could find no improvements in the ways medicines were managed. There were no care plans or risk assessments relating to medicines. One of the people we visited had their eye drops administered by staff. Their care plan just stated that staff should give the eye drops, there was none of the information we would have expected about how this should be done.

In August 2011 the manager had found gaps on this person's medicine administration record. This meant that it was not possible to be sure that the person had received their eye drops as they were prescribed. The manager had instructed staff to sign the sheet retrospectively, which was not safe practice. We found there were also a number of gaps on the record for September and October.

Another person's medicine administration record had become detached from the instructions set out by the pharmacist, which meant that there was no record to show exactly what medicines staff were signing for. This could increase the potential for errors and put people using the service at risk. We asked the manager to address this issue as a matter of urgency. We later received confirmation from the manager that a new medication administration record was in use the day after our inspection.

One person had three partially used boxes of tablets that had been dispensed by the chemist in October last year and July and September of this year. There were no records to enable medicines to be audited; therefore we were not able to tell why these tablets had not been given. Medicines no longer in use should be returned to the chemist to reduce the risk of errors.